Gastroenterology Fellowship Curriculum

On this rotation, fellows work one-on-one with faculty seeing outpatient consultations covering the full spectrum of gastroenterology and hepatology.  First-year fellows rotate with experienced faculty seeing general GI consults from our academic and community primary care practices, gaining experience as an outpatient consultant and as a managing subspecialist.

Upper-level fellows rotate with expert faculty seeing patients with challenging sub-subspecialty complications of:

• inflammatory bowel disease
• liver disease
• pancreaticobiliary disease
• neuromuscular disease of the GI tract

On this procedurally-focused rotation, fellows work one-on-one with expert faculty evaluating and managing patients with challenging diseases of the pancreas and biliary system. Fellows achieve substantial experience in performing ERCP, sphincterotomy and stent placement in the biliary and pancreatic ducts. Fellows also gain experience in advanced endoscopic techniques such as complex dilations, enteral stent placement, cystgastrostomy and pancreatic necrosectomy.

Because our busy endoscopic ultrasound service is involved in the evaluation of many of these patients, fellows on this rotation also gain a significant exposure to this important technology, although we believe that formal training in EUS requires an additional year of training. In collaboration with our busy bariatric surgical service, fellows also gain hands-on experience in the ever-growing field of endoscopic management of complications of these surgeries.

On this rotation, fellows work one-on-one with expert faculty reviewing images generated from wireless capsule endoscopy studies. Fellows gain experience in evaluating challenging diseases of the small bowel, including occult gastrointestinal bleeding, small bowel neoplasms and ulcerating diseases of the small bowel.

The GI Consult Service serves Wake Forest Baptist Medical Center, an 830-bed hospital that provides tertiary and quaternary care to a four-state area, as well as serving the citizens of Winston-Salem. Since we do not have an inpatient GI or Liver service, we see all patients with these disorders in a consultative role. The patients we see span the breadth of gastroenterology, and about one-third of these consults are for liver disorders.

The team is made up of one faculty, two fellows (one first-year fellow and one upper-level fellow), two internal medicine residents and up to two medical students. The two fellows alternate days of seeing new consults or performing procedures, which typically allows the fellow to perform procedures on a patient they performed the consult on the previous day. Residents and medical students are available to help with consults and the fellow participates in a supervisory role in their education. This structure has allowed this intensive experience to be educational and enjoyable, with time for reading and reflection.

Each fellow has one half-day of clinic every week during the three years of fellowship. In this ambulatory experience, the fellow manages his or her own panel of patients with GI and liver disorders. The fellow has primary responsibility for the care of these patients, and plans for evaluation and management are designed under the guidance of a faculty preceptor. This experience involves new patient consultations, as well as giving each fellow the opportunity to develop longitudinal relationships with patients with chronic GI and liver disorders over the course of three years.

During the second and third years of fellowship, elective rotations are offered, with the goal of meeting each fellow’s individualized training needs for his or her specific career plans. These elective opportunities range from self-designed elective experiences to established, highly structured experiences.

An example of the latter is the Transplant Hepatology Rotation at Atrium Health in Charlotte, NC. During this rotation, the fellow participates in the full transplant experience, including outpatient evaluation of chronic liver disease patients for transplant candidacy, inpatient care of acutely ill patients awaiting transplantation, operating room observation of a liver transplantation and post-operative care of transplanted patients.

Another popular elective rotation has been a significant endoscopic retrograde cholangiopancreatography (ERCP) experience with our clinical faculty at the nearby community medical center. Each fellow meets with the program director prior to each elective rotation to discuss specific plans, with the overarching goal of a tailored preparation of each fellow for their individualized future career plans.

On this rotation, fellows develop their procedural skills performing esophagogastroduodenoscopy (EGD) and colonoscopy under the direct one-on-one supervision of the GI faculty. Patients seen on this rotation are referred for ambulatory procedures, including diagnostic and therapeutic EGD, colonoscopy and flexible sigmoidoscopy for a variety of indications.

On this rotation, fellows gain experience in performing mucosal biopsy, polypectomy, endoscopic mucosal resection, esophageal dilation, variceal banding, Botox injection and Argon Plasma Coagulator treatment of AVMs under the tutelage of experienced faculty. The structure allows the fellow to review and discuss the pathology results with the attending supervising the fellow to augment the educational experience.

On this rotation, fellows work one-on-one with our expert hepatology faculty seeing a variety of liver diseases. The experience includes outpatient clinics or ambulatory procedures in the mornings and rounding with the hepatology consult attending or ambulatory clinics in the afternoon. This rotation is assigned during the first year and repeated during the second year of fellowship. Fellows looking to gain additional training in hepatology can use elective time for additional hepatology electives, including the Transplant Hepatology Elective (see Elective Rotations).

This rotation, completed during the first year of fellowship, is designed to give the fellows experience managing complex IBD patients. Fellows will work directly with our IBD faculty in their ambulatory clinics. They will also participate in the Multidisciplinary IBD Clinic staffed by both colorectal surgeons and IBD faculty to gain experience in co-management of complex patients using a team approach to provide patients with the best care. Fellows will additionally participate in ambulatory procedures being performed by IBD faculty.

On this rotation, fellows gain formal training and hands-on experience with state-of-the-art equipment performing esophageal and anorectal manometry, ambulatory pH and impedance studies, hydrogen breath tests, electrogastrography and SmartPill studies. This one-on-one training experience with world-renowned faculty also includes seeing ambulatory patients referred for the evaluation and management of complex neuromuscular GI disorders.

The research experience for fellows is made up of two components: a traditional clinical investigation project and a quality improvement project.

At the beginning of fellowship, we use a formal process to help each fellow identify a research mentor based on her or his research interests. Together with his or her mentor, each fellow will design a clinical research project, usher it through the IRB process, carry it out and collect and analyze the data. There is an expectation that each project will result in a poster presentation at the national meeting of one of our GI societies (AGA, ASGE, ACG, or AASLD) and will culminate in the submission of a manuscript for publication in one of the peer-reviewed journals of our subspecialty.

For the quality improvement project, during the first year of fellowship each fellow will gather baseline data from his or her continuity clinic or on the consult services and design an intervention for improvement in some aspect of clinical care. The intervention will be implemented during the second year of fellowship, and the data will be analyzed and presented during the third year of fellowship. It is hoped that these projects will also produce posters and publications. A total of six months of protected time is provided for each fellow for these research endeavors. Additional time for research can be elected in the third year of fellowship.

These rotations are designed to give fellows experience with faculty outside of the GI department who treat related conditions. During the colorectal surgery rotation, fellows work in the clinics and the operating room with our colorectal surgeons to gain experience treating and managing anorectal disorders from a surgical standpoint. On the nutrition rotation, fellows will spend time in the operating room observing bariatric surgery, in the medical weight loss clinic, with nutritionists in the medical weight loss clinic, and with the TPN pharmacists.

The VA Medical Center serves as a major training site for our GI Fellowship program. Although this is a comprehensive experience in gastroenterology and hepatology, including outpatient clinic evaluations and inpatient consultation, the main focus of this rotation is training in colonoscopy and EGD.

Endoscopic training begins with a state-of-the-art simulator, followed by experience with patients referred for outpatient endoscopy; these procedures are scheduled in a manner to allow first-year fellows extra time as they develop their endoscopic skills. Upper-level fellows are allowed progressive autonomy in performing procedures at this training site, meaning the fellow performs the procedure independently with the attending available through indirect supervision.

This conference focuses on the key topics of our subspecialty and is designed to cover each of these topics over an 18-month period of time. This allows each fellow to be exposed to each subject matter in this format twice over the course of his or her fellowship. These presentations typically focus on the evaluation and management of the core diseases of our subspecialty, as well as the underlying basic science and pathophysiology.

These case-based conferences focus on the evaluation and management of interesting and instructive cases of gastrointestinal and liver disease, with an emphasis on the underlying evidence that guides our practice.  The cases discussed include inpatients and outpatients, cognitive and procedural challenges, and acute and chronic illnesses across the spectrum of our subspecialty.   These presentations and discussions include the radiologic, pathologic, and surgical components of the evaluation and management of these patients.

• Liver Conference – cases are presented by GI Fellows to our Hepatology faculty.  These cases focus on diagnostic challenges, management of unusual liver diseases, updates in the treatment of viral hepatitis, and the prominent role of liver transplantation in the management of acute liver failure and chronic liver disease. Hepatologists from the Atrium Health Liver Transplant program have a Wake Forest faculty appointment and are also an integral part of our fellowship training program.
  
  
• Radiology Conference –  cases are presented by GI Fellows to the faculty of our GI Radiology department.  The teaching in this conference emphasizes the optimal utility of the various imaging and intervention techniques used in the evaluation and management of patients with GI and Liver diseases.  There is also an emphasis on developing the skills of the GI fellows and faculty in the interpretation of plain films, CT, ultrasound, and MRI of the gastrointestinal tract.
  
  
• Pathology Conference – cases are presented by GI Fellows to the faculty of our GI Pathology department.   This conference accentuates the central role that histology plays in the evaluation and management of GI and Liver disease, with an emphasis on developing the skills of the GI fellows and faculty in the interpretation of biopsies of the gastrointestinal tract and liver.
  
  
• GI Surgery Conference – challenging cases are presented by Surgery faculty and residents, as well as GI faculty and fellows.  Cases are selected for which there is insufficient evidence to guide a straightforward management plan.  Robust discussions rely on the in-the-trenches experience of the faculty and fellows as various clinical strategies are debated.
  
  
• GI Oncology Conferences – these working conferences involve an in-depth discussion of patients with newly-diagnosed cancers of the GI tract and liver.  Surgical oncologists, medical oncologists, radiation oncologists, interventional radiologists, diagnostic radiologists, and gastroenterologists work collaboratively to design the best treatment plan for each patient.  These specialists review and rely heavily on the best available evidence to guide these discussions.
  
  
• Morbidity and Mortality Conference – we have a passion for quality care at Wake Forest, and we take each of our complications very seriously.  In this closed meeting for faculty and fellows, we examine each case to try to understand what went wrong and how the complication could have been prevented.   This is a positive, collaborative process, guided by an attitude of humility and respect, with the fundamental goal of learning from each other’s mistakes and improving care for our patients in the future.

We take a unique approach to interpretation of medical literature compared to many programs. Our journal club conferences comprise two separate types of journal article reviews. We have a more traditional Journal Club Conference that focuses on in-depth analysis of an article focusing on how to dissect and critically appraise a journal article. Additionally, we host a GI Current Events Conference designed to cover the breadth of GI literature rather than focusing on in-depth review. This is designed to steer attendees to interesting articles they might have otherwise missed and allow them to do independent in-depth analysis at their convenience.

Our research conference serves several different functions.   There are didactic sessions on how to achieve success in a research project, including how best to work through the IRB process, and tips on preparing a manuscript for submission for publication, for example.  This conference also serves as a venue where fellows and faculty present their clinical and quality research projects in progress, in order to get ideas for improvement from the group.  In the same vein, conference time just prior to our national meetings (DDW, ACG, AALSD) is used by fellows and faculty to get feedback in preparation for their poster and oral presentations.

This interdisciplinary conference consists of a round-table discussion with nutritionists, PharmDs, and gastroenterologists discussing challenges of enteral and parenteral nutrition. In addition to discussion of individual patients, there is a focus on the evidence which guides best practices in nutritional support.

A primary goal of our fellowship is for each fellow to pass the ABIM exam in Gastroenterology on the first attempt. In this conference, a GI faculty presents a brief didactic session focused on knowledge expected to be covered on the certifying exam, followed by an interactive discussion of practice board exam questions with the fellows.